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130 PRESTON EXECUTIVE DRIVE CARY, NORTH CAROLINA 27513 ×p× 9194628081 ×f× 9194628082 www.parkwaysleep.com AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS Patient Name: DOB: Address: City×State×Zip:

How to fill out release medical records to

How to Fill Out Release Medical Records Form:

1. Begin by locating the required release medical records form. This form is typically provided by the healthcare facility or provider where your medical records are held.
2. Fill in your personal information accurately. This includes your full name, address, date of birth, phone number, and any other details requested on the form.
3. Specify the purpose of the release. Indicate the individual or organization you want to authorize to receive your medical records. Provide their name, contact information, and their relationship to you, if applicable.
4. Clearly state the duration for which the release is valid. You can choose to specify a specific time period, such as one year, or indicate that the release is ongoing until revoked by you in writing.
5. Review and sign the form. Make sure to read through the entire form carefully before signing it. By signing the form, you are authorizing the designated individual or organization to access your medical records.
6. Complete any additional sections or requirements mentioned on the form. Some forms may ask for additional information, such as the specific types of medical records you want to release or any restrictions you would like to place on the release.
7. Make a copy of the completed form for your records. It is important to keep a copy of the signed release medical records form for your own reference.
8. Submit the form to the appropriate healthcare provider or facility. Follow the instructions provided on the form to ensure that it reaches the intended recipient.

Who Needs Release Medical Records To:

1. Various entities may require access to your medical records. These can include healthcare providers, insurance companies, legal representatives, government agencies, or research institutions.
2. If you are changing healthcare providers, your new provider may request your previous medical records to gain a comprehensive understanding of your medical history and make informed treatment decisions.
3. Insurance companies may require your medical records when processing claims, determining eligibility for coverage, or conducting medical reviews.
4. Legal representatives may need access to your medical records for the purpose of a personal injury or medical malpractice lawsuit.
5. Government agencies, such as the Social Security Administration or the Department of Veterans Affairs, may require your medical records to evaluate disability claims.
6. Research institutions may request access to your medical records for scientific studies or clinical trials.
7. It is important to carefully consider the purpose and legitimacy of each request before authorizing the release of your medical records to ensure your privacy and confidentiality are protected.

In summary, filling out a release medical records form involves providing accurate personal information, specifying the recipient, stating the duration of the release, reviewing and signing the form, and submitting it to the appropriate healthcare provider. The individuals or organizations that may need access to your medical records include healthcare providers, insurance companies, legal representatives, government agencies, and research institutions. Always carefully evaluate each request to protect your privacy and confidentiality.

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